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Under the direction of the Chief Quality Officer, the Senior Director, Regulatory Affairs directs the strategic management and planning for the Joint Commission (TJC) and accreditation related activities for clinical services throughout Baystate Health, including all licensed sites. The Senior Director, Regulatory Affairs develops a comprehensive accreditation program to ensure: 1) BH complies with all federal, state and TJC standards; 2) all administrative and clinical leaders are kept abreast of state, federal and Joint Commission requirements; 3) requirements are audited and reported on a systematic basis, and 4) that opportunities for improvement are identified, communicated and monitored. This Director also oversees and supports all regulatory communications and on site regulatory visits. The position requires expert knowledge in federal, state and TJC standards and clinical and operational expertise to achieve and maintain a continuous state of readiness. This includes, but is not limited to, functioning as an expert resource and consultant to the organization, as a liaison between the organization and accreditation or regulatory bodies, and as a resource in continuous improvement activities. The Senior Director, Regulatory Affairs works directly with the executive leadership, clinical and administrative leadership, and supports colleagues in all roles across the organization.

The role of leaders at Baystate Health is, first and foremost to, work towards Advancing Care & Enhancing Lives for our diverse patients, community and staff. Baystate Leaders are expected to act as dynamic stewards of the organization and to engage people in meaningful work that calls on each person to contribute what they do best in order to ensure organizational success. It is especially important that our leaders act in a way that demonstrates compassion, inclusiveness and raising the standard of excellence. Baystate Health is committed to the development and growth of its leaders and expects that its leaders, in turn, are committed to their own development and growth as well as that of all employees. Baystate Leaders continuously develop the competencies that better enable them to envision purpose, engage people and execute productively, thus allowing us to fulfill our mission and achieve our vision of transforming Healthcare.

Envisioning Strategy: Communicate a compelling vision of the organization’s future and effectively translate that into Divisional/Departmental and Individual goals.

Engaging People: Recruit, develop and position people utilizing their strengths. Create and promote an inclusive environment in which people are actively engaged, included and inspired to do their best to continuously improve individual and organizational effectiveness.

Executing to Achieve Results: Implement complex plans to achieve results through others with creative and sustainable solutions.

• Assesses hospital compliance with accreditation standards and regulations related to clinical care in collaboration with leadership and staff. Identifies areas of vulnerability and directs the development of strategies to enhance compliance.

• Coordinates hospital clinical compliance activities to ensure that hospital is in compliance and has an integrated, consistent plan for continuously complying with all required CMS, DPH, Mass Health regulations and Joint Commission standards.

• Assesses hospital compliance with accreditation standards and regulations related to clinical care in collaboration with leadership and staff. Identifies areas of vulnerability and directs the development of strategies to enhance compliance.

• Directs all organizational continuous readiness/ accreditation activities including but not limited to: serving as primary contact for TJC communication; managing operational aspects of accreditation applications; completing and submitting all JC accreditation process requirements; participating in ongoing standards assessment and the development of action plans for prioritized risks; reporting individual and system wide opportunities for improvement to operational managers and clinical and administrative leaders.

• Coordinates formal accreditation, regulatory or licensure on-site surveys. Develops and maintains a logistics plan for survey execution. Acts as the primary liaison with the survey team. Coordinates the development, implementation and monitoring of corrective action plans in response to TJC surveys. Collaborates with Risk Management and Patient Safety to assist in on-site surveys and in the development, implementation and monitoring of CMS or state surveys.

• Provides consultative services to all levels of the organization on accreditation/ regulatory issues, interpretation of standards and policies, and linkage to clinical and operational processes.

• Educates the organization and staff by leading readiness steering and management teams: integrating elements of ongoing readiness into leadership meetings, resident orientation, and committee meetings. Reinforcing systems or processes that support the delivery of safe, high quality, patient-centered care.

• Partners with the departments of QualitySafety, Risk Management and Human Resources to leverage opportunities to sustain compliance with best practices as part of existing improvement teams.

Required Experience:

5 years relevant experience in a similar role or role leading towards progressive regulatory responsibility

Preferred Experience:

7 years relevant experience in a similar role or role leading towards progressive regulatory responsibility

Education: Requires a Bachelors degree with a Masters Degree preferred.

Skills/Competencies:

Excellent oral and written communication and facilitation skills. Ability to build cross system relationships. Understanding and application of clinical laws and regulations

THE ADVANTAGES OF WORKING WITH BAYSTATE!

• Excellent Compensation High-quality, low-cost medical, dental and vision insurance

• Generous PTO – up to 25 days in the first year, with scheduled earned increases

• Continuing education support and reimbursement

• First Time Home Buyers Financial Packages

• Farm Share Memberships

• 403b retirement company match & annual company contribution increase based on years of service

• Free money coach advice from a certified professional

• Wellbeing programs that include but are not limited to mental, physical, and financial health

• Pet, home, auto and personal insurance

• Life insurance

• Reimbursement for a variety of wellbeing activities, included but limited to gym membership and equipment, personal trainer, massage and so much more!

• Wellbeing programs that include but are not limited to mental, physical, and financial health

Baystate Health, western Massachusetts’ only academic center and tertiary care provider has a long and proud tradition of continuous learning and improvement. We educate and train hundreds of healthcare workers every year and advance knowledge about new approaches to care. At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. We are committed to increasing diverse representation across our organization. Together our inspired and compassionate teams manage the whole health needs of all communities in need.

We strive to be the place where we can help you build the career you deserve – apply today – YOU belong at Baystate!

OUR COMPENSATION PHILOSOPHY

We offer competitive total compensation that includes pay, benefits, and other recognition programs for our employees. The base pay range shown above considers the wide range of factors that are considered in making compensation decisions including knowledge/skills; relevant experience and training; education/certifications/licensure; and other business and organizational factors. This base pay range does not include our comprehensive benefits package and any incentive payments that may be applicable to this role.

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

Education:

Master of Science (Required)

Certifications:

Registered Nurse - Other

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

Ab out Baystate Health

Baystate Health (BH) is one of New England’s leading and largest integrated health care organizations, serving a population of nearly one million people throughout western New England. With roots dating back to the founding of Springfield City Hospital in 1873, Baystate Health has been providing high-quality and compassionate health care in western Massachusetts for more than 145 years. With more than 12,000 employees, a medical staff of nearly 3,100 physicians, and a net patient service revenue of more than $1.4 billion, the ever-growing health system includes five Massachusetts hospitals and the Baystate Mary Lane Outpatient Center in Ware:

• Baystate Medical Center in Springfield

• Baystate Children’s Hospital (located at Baystate Medical Center)

• Baystate Franklin Medical Center in Greenfield

• Baystate Wing Hospital in Palmer

• Baystate Noble Hospital in Westfield